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BOARD OF PUBLIC WORKS <br />AGENDA ITEM RE VIEW REQUEST FORM <br />Date 12/07/17 Department Public Works <br />Name Toy Villa Division/Bureau Engineering <br />BPW Date 12/21/17 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal Attorney Name: <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />H Agreement <br />H Contract Lj Proposal H Addendum <br />El <br />Professional Services <br />El <br />Resolution <br />El <br />Bid Opening <br />0 <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />R Quote Opening <br />F-1 <br />Quote Award <br />❑ Change Order No. 3 <br />R C/O & PCA No. ❑ PCA <br />Ease/Encroach. <br />F-1 Traffic Control: <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBENVBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Selge Construction <br />El Yes Z No El If Yes, Approved by Purchasing <br />[I M:BE [—] WBE <br />F1 No 0 Yes Name of Company <br />Western Avenue Corridor Improvements from Bendix Drive to <br />Olive Street <br />115-097 (16JW01) <br />RWDA TIF <br />324.1050.460.42.03 <br />Approval of C,O. #3 <br />F-1 Required Contractor's Certification Forms Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Ver,ifv. Iran. etc. <br />Amount of H Increase $ 61,46832 <br />El Decrease $ <br />Previous Amount $ 2,798,77143 <br />Current Percent of Change: 2.20% <br />New Amount $ 2,860,242.15 <br />Total Percent of Change: 5.42% <br />Copy <br />Original <br />F1 <br />F-1 <br />El <br />11 <br />El <br />El <br />